Signs & Symptoms

As with acute heart failure, it is difficult to define specific symptoms for advanced heart failure outside the general symptom complex of heart failure.

The predominant clinical features are discussed in the acute heart failure signs and symptoms section. The most common symptoms attributable to heart failure are dyspnoea, fatigue, weight gain and fluid retention evident as peripheral oedema, and ascites.

A potentially helpful manner in which to approach the clinical evaluation of someone with advanced heart failure can be to consider symptoms in terms of degree of congestion (wet or dry) and degree of perfusion (hot or cold) (Nohria et al., 2002). This can largely be done by gathering clinical information from examination of the neck veins, lungs, abdomen and extremities. Hypoperfusion can be indicated by cool extremities, fatigue, narrow pulse pressure and evidence of worsening renal function. Congestion is suggested by high jugular venous pressure, oedema, ascites and orthopnoea. Figure 2 provides a visual representation of the potential states arising by using this method to break down the clinical picture (Nohria et al., 2001; Mentz & O’Connor, 2016).

From Figure 2, the desired state is clinical profile ‘A’, where the patient is well perfused, without any clinically-notable oedema. Most patients requiring hospital admission will exhibit clinical profile ‘B’; where symptoms relating to venous congestion are predominant over those of hypoperfusion. In advanced heart failure, clinical profile ‘C’ may be notable, as patients with congestive symptoms and oedema require a balance to be struck in management terms (Mentz & O’Connor, 2016).

The most sensitive clinical findings that determine poor prognosis are a raised jugular venous pressure and a third heart sound, or S3 ‘gallop’ rhythm (Figure 3) (Drazner et al., 2001).

Figure 3. Visual representation of the sounds of an S3 ‘gallop’ rhythm on precordial auscultation (adapted from Drazner et al., 2001). The third heart sound is caused by a sudden deceleration of blood flow from the left atrium into the ventricle.